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Peripheral Vascular Disease in Cardiac Patients

Peripheral Vascular Disease in Cardiac Patients. Jason Finkelstein, M.D. Cardiology Fellow Tulane University HSC 9/23/03. P A D. Characterized by arterial stenosis and occlusions in the peripheral arterial bed Can be symptomatic or asymptomatic Under diagnosed and under treated disease

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Peripheral Vascular Disease in Cardiac Patients

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  1. Peripheral Vascular Disease in Cardiac Patients Jason Finkelstein, M.D. Cardiology Fellow Tulane University HSC 9/23/03

  2. P A D Characterized by arterial stenosis and occlusions in the peripheral arterial bed • Can be symptomatic or asymptomatic • Under diagnosed and under treated disease • Patient and physician awareness is low

  3. P V D • Ranges in severity from intermittent claudication to limb ischemia • Patients have a decreased quality of life due to a reduction in walking distance and speed leading to immobility • Most cases of PAD are asymptomatic

  4. Prevalence • 27 million people in Europe and North America have PAD (16% of the population 55 yrs or older) • 10.5 million are symptomatic • 16.5 million are asymptomatic • Three recent programs have demonstrated high PAD detection rates when specific populations were at risk for PAD were screened

  5. POPADAD study • 8000 patients • 40 yrs or older with DM Type I or II • Had no clinical symptoms of arterial disease • Results: • 20.1% of patients had ABI < 0.9

  6. PAD Awareness & Detection • Total of 6979 patients • Ages 70 yrs or older or 50-69 with diabetes or smoking history • PAD was considered present if ABI< 0.9 or a h/x of limb revascularization • CVD was defined as coronary, cerebral, or aortic aneurysmal disease • Criqui, et al, JAMA 2001: 286; 1317-1324

  7. Results: • PAD was detected in 1865 pts ( 30%) • 44% of these pts had newly diagnosed PAD only • 366 pts had newly diagnosed PAD and CVD (35%) • Among pts with PVD, classic claudication was distinctly uncommon • PAD is relatively underdiagnosed by physicians • PAD patients were less intensely treated than patients with CVD • Criqui et al, JAMA 2001 286. 1317-1324

  8. Natural History of PAD • Associated with significant mortality because of association with coronary and cerebrovascular events including death, MI, and stroke • 6x more likely to die within 10 yrs than patients without PAD • 5 yr mortality rate in pts with claudication is about 30% • Continued use of smoking results in a two fold risk of mortality

  9. Prevalence • Severity of symptoms has been found to correlate with survival • San Diego Artery study • Survival rates decreased with increasing severity • Another study showed that patients with symptoms had a 22% survival rate over a 15 yr period compared to a 78% survival rate of pts w/o symptoms • Belch et al, Arch Intern Med; April 2003; 884-892

  10. Predictors of Mortality in PAD • 297 patients • 213 had intermittent claudication • 84 had CLI defined by gangrene, ulcerations or persistent rest pain > 2 weeks • All subjects had ABI < 0.9 • Results • Patients with CLI had a 1 yr death rate of 22% • 3 yr survival was 52% compared to 86% in pts with intermittent claudication • Data suggests that pts with advance PAD have widespread arteriosclerotic disease • CLI was a stronger predictor of death than a low ABI Pasaqualini et al, Amer Jour of Cardio 2001;Vol 88:1057-60

  11. Claudication • Patients suffer from peripheral atherosclerosis • Symptomatic deficiency in blood supply to exercising muscle which is relieved by rest • Largely a disorder of the elderly • Only 1-2% of those ages 37-69 • Clinical history extremely important

  12. Risk Factors • Diabetes mellitus • have worse arterial disease and poorer outcomes than non-diabetics • Advanced age • Hyperlipidemia • Cigarette smoking • Hypertension

  13. Cardiac Risk • Pts with PVD have a 60% risk of CAD • Up to 30 % of pts have correctable 3 vessel disease with reduced LVEF • Patients with an ABI < 0.9 are twice as likely to have CAD

  14. Clinical Presentation • Can vary from severe disabling discomfort at rest to a bothersome pain of seemingly little consequence • Can present with buttock, thigh, calf or foot claudication singly or in combination • Diminished pulses with occasional bruits over stenotic lesions • Poor wound healing, unilateral cool extremity, shiny skin, hair loss, and nail changes

  15. Claudication • Calf • Cramping in upper 2/3 usually due to SFA stenosis • Thigh • Usually occlusion of the common femoral artery • Foot • Occlusive disease of the tibial and peroneal vessels • Buttock and Hip • Aortoiliac occlusive disease (Lariche’s syndrome)

  16. Diagnostic tests • Ankle-brachial index • Measures the resting and post exercise systolic BP in both the ankle and arms • Normal > 1.0 • Below 0.9 has a 95 % sensitivity for detecting angiogram positive PVD • 0.4 to 0.9 suggests arterial obstruction • Highly predictive of morbidity and mortality of CV events linked to PAD • Below 0.4 represents advanced ischemia

  17. Diagnostic Tests • Segemental limb pressures • > 20 mmHg reduction significant • Duplex U/S • MRA • Conventional angiography

  18. Angiography • Indicated for: • Defining vessel anatomy • Evaluating therapy • Documenting disease

  19. Long term survival • 2, 296 patients reviewed from CASS found to have PAD • Mean follow up period was 10.4 yrs • Pts with PAD had a higher frequency of CV risk factors • HTN, DM, CHF, previous CABG, or smoked • Controlled for all independent risk factors • Vascular disease retained a highly significant correlation with mortality • Pts had a 25% increased risk of dying at any time during followup ( p< 0.001) Eagle et al, JACC 1994;23:1091-5

  20. Premature PAD • 59 male patients with premature PAD • Age of onset < 45 yrs of age • PAD assessed by ABI and CAD assessed by exercise treadmill testing or coronary angiogram • Mean ABI was 0.65 • Arteriography performed in 56/59 pts • Valentine et al, J of Vasc Surg (1994; 19; 668-674)

  21. Premature PAD • 30 month period of the study • 43 patients had significant CAD (73%) • 17 pts had single vessel disease • 4 pts had 2 vessel disease • 22 pts had 3 vessel disease • 32 pts experienced an MI and 23 pts requires an intervention to help control angina • 8% mortality rate in the study • Valentine et al, J Vasc Surg (1994; 19:668-674)

  22. Management of PAD & CAD • Close association of PAD and CAD • Pts with CAD undergoing PV surgery are at increased risk of early and late CV events • Coronary revasc. is likely to improve outcome but mortality rate after CABG is not as good as in pts w/o PVD • Recommends hemodynamic monitoring • Definitive guidelines are not available • Gersch et al, J am Coll Card; 1991;18:203-214

  23. PVD and Role of CRP • 51 pts with PVD who underwent lower limb revasc. (screened 170 pts) • 24 month f/u period • 39 pts had PTA and 12 pts had bypass surgery • CRP levels were measured pre-op All mortality, cardiac mortality and MI were considered major events • Rossi et al, Circulation 2002; 105:800-803

  24. PVD and Role of CRP • 34% incidence of fatal and nonfatal MI over 2 yrs • CRP > 9 predicted 60 % o f MI’s in pts undergoing lower limb revasc. ( p <0.04) • Conclusion • CRP level in pts with PVD severe enough for revasc. may give incremental information about CV events and had a high predictive value • Pts may benefit from therapy modulating the immune response • More studies needed • Rossi et al, Circulation; 2002; 105: 800-803

  25. PAD Management • Anti-platelet agents • Diabetic control • Smoking cessation • Anti-hypertensives • Statin therapy • Exercise rehabilitation • Revascularization/PTCA/stenting

  26. Revascularization • Indications for intervention (PTA) • Persistent limiting claudication that prevents patient from performing daily activities • Rest pain • Tissue loss • Patients who are poor surgical candidates • Long term success of PTA depends on site and length of the lesion • Limited to focal, short segment occlusions • No significant difference in outcome between PTA or surgery

  27. Revascularization • Lesions might be better treated surgically if: • Long segments • Multi focal stenoses • Long segment occlusions • Eccentric, calcified lesions

  28. Conclusion • Need to increase awareness of PAD and its consequences • Improve the identification of patients with symptomatic PAD • Initiate a screening protocol at high risk for PAD • Improve treatment rates for those who have been diagnosed • Increase the rates of early detection in asymptomatic patients

  29. Summary • PAD is a powerful indicator of systemic artherosclerosis • Mandates aggressive risk factor modification and pharmacologic therapy • Goal is to improve the functional capacity of our patients and decrease morbidity and mortality • Cardiologists need to take a more active role in treating PAD along with co-existing CAD

  30. Case #1 • Mr. EG is a 52 yr old male with PMHx of HTN, tobacco abuse and CAD with a 5 vessel CABG in June 2000 • LIMA – LAD • SVG to D1 • SVG to OM1 & OM2 • SVG to RCA

  31. Case #1 • Last cath was in April of 2001 which showed patent grafts and medical management was recommended • Now pt has recurrent chest pain on exertion < 1 block • Cardiolyte stress test revealed 1 mm ST depression and anterior ischemia. LVEF is 44%

  32. Case # 2 • Mr. JG is a 60 yr old male with PMHx of severe tobacco abuse, AAA, PVD with ischemic rest pain, Right CEA, HTN, who presents with occasional atypical angina • Persantine Cardiolyte stress test showed reversible anterior and septal ischemia

  33. Case # 2 • TEE revealed normal LVEF with mild inferobasal HK • Moderate to severe eccentric MR • Physical exam revealed b/l carotid bruits and 2/6 SEM

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